Cor Pulmonale in Pulmonary Tuberculosis A preliminary report on 66 patients BY S. C. KAPOOR (Silver Jubilee Tuberculosis Hospital, Kingsway Delhi-9.) Till recently pulmonary tuberculosis had not been regarded as an important cause of Cor pulmonale. Most of us had not seen more than one or two cases of pulmonary tuberculosis die of right heart failure. During the last five or six years, however, we have seen this complication occur more and more frequently in tuberculosis patients and in this Institution, we have seen it often enought to sit up and take notice. MATERIAL AND METHODS The definition or Cor Pulmonale not being fully agreed upon, it would probably be best to make our criteria of diagnosing this condition clear. We have stuck to White's original definition, except that congestive heart failure has not been considered an essential component of “the picture, in view of more modern views. We are not in agreement with the school that considers every case of pulmonary hypertension as Cor Pulmonale, be it due to left sided heart diseases even (Brill, 1958). Our main bases of diagnosis have been, (i) no evidence of other heart disease, (ii) definite right heart failure or (iii) at least two of the common clinical features and/or (iv) unequivocal electrocardiagrophic evidence. No patient has been diagnosed as having Cor Pulmonable on just one finding, unless unequivocal. The cases reviewed in this report have all been discovered in the routine course of observation, and are not the result of a deliberate survey. Our usual case, apart from the grossly evident ones, has been found during a somewhat perfunctory examination of the heart or during an electrocardiographic examination for some other suspicion, and as such, this report in no way deals with the incidence of this condition. All cases reported had a thorough clinical, radiological and electrocardio- graphic examination, the two former being in serial in most cases. Most of these cases were discovered during the last year and a half and, excluding the deaths, the period of observation has ranged between one month and four years, averaging a little less than one year. OBSERVATIONS The findings are recorded in Tables 1 to 8. TABLE 1 Age Incidence Age Group Male Female Total Below 10 years 1 1 2 11 to 20 „ 4 7 11 21 to 30 „ 15 16 31 31 to 40 „ 6 1 7 41 to 50 „ 8 1 9 Over 50 years 5 1 6 Total 39 27 66 Ind. J. Tub., Vol. VI, No. 2 S. C. KAPOOR 51 Of a total of 66 patients, men numbered 39 and women 27, the largest incidence in either being between the ages of 21 and 30 years. Among women, 22 of the 27 were between 16 and 30 years, whereas, in men, the higher age groups also contributed a fair proportion of cases. Our youngest patient was a girl 6 years old, and our oldest, a man of 66. TABLE II Duration of Lung Disease Duration Number Less than 1 year 10 1 to 2 years. 21 2 to 3 „ 11 3 to 4 9 4 to 5 „ 5 More than 5 years 10 Range: — 6 months to 28 years. The total known duration of disease before the diagnosis of Cor Pulmonale again shows extremes of 6 months and 28 years. As is seen in Table II the largest number of cases, about 30% had suffered from more than one, and less than two years. TABLE III (a) Extent of lung disease Red. Involvement less than 1 lobe (Total area) 24 „ „ more t h an 1 l o b e an d l ess t h an one lung field 27 „ „ more than one lung field 15 (b) Type of disease Giant Cavities 21 Diffuse Fibrosis 24 Radiological involvement (Table III) of more than one lung field was present in less than one-fourth of the cases, giant cavities and/or diffuse, discrete Ind. J. Tub., Vol. VI, No. 2, COR PULMONALE IN PULMONARY TUBERCULOSIS 52 fibrosis having each been present in roughly one-third of the cases. The majority of the patients showed a total lung involvement less than one lung field in area. TABLE IV Other Clinical Features Dyspnoea 39 cases Palpitations 21 „ Rhonchi 17 „ Prolonged exp. and other evidence of Bronchospasm 36 „ Clubbing 13 „ Cyanosis 14 „ No symptoms 21 „ Symptoms suggestive of heart involvement were absent in 21 of the patients, (see Table IV) and suggestive clinical signs were present in 10 of them. The most constant physical sign leading to consideration of Cor Pulmonale in these patients TABLE V Heart Findings (a) Clinical Failure 16 Cases Parasternal Pulsation . 34 „ Lou d P, ( w i t h or w i t h out pat h o- logical split) 50 „ Diastolic Murmur 6 „ Systolic Murmur 13 „ Poor Heart Sounds etc. 10 „ No. findings 10 „ Loud A, 1 „ Pericardial fluid 2 „ (A) Radiological Enl. of P. A. 35 „ Enl. Heart shadow or only R. V. enlargement 21 „ was a loud pulmonary second sound, seen in SO patients, about thirty of them showing a pathological splitting. Parasternal heave was fairly common, occurring in about half of the cases, but was not so well developed in all of them. Radiological Ind. J. Tub., Vol. VI, No. 2, 53 S. C. KAPOOR appearances were of least help. Although 35 of the cases are shown as haying enlarged pulmonary artery shadows, in over half of them, this conclusion was arrived at on examination of serial skiagrams after the diagnosis of Cor Pulmonale and was too minor to have been noticed unless specifically looked for. Even a biased observer might have missed it in a single film. The same is true of enlargements of the cardiac silhoutte. (see Table V). The electrocardiogram was pur best diagnostic help. All the cases gave electrocardi graphic evidence suggestive of Cor Pulmonale. TABLE VI Electro Cartographic Findings P Pulmonale -64 Casec in limb leads only 18 „ in chest leads only 6 „ in both 40 „ Right vent. Hypertrophy 39 „ R. Bundle Branch Block 11 „ Negative T in more than 2 leads 26 „ Very high T in chest leads 5 „ Extra systoles 6 „ Poor voltage 8 „ Dextrocardia 1 „ Total cases examined 66 „ Pulmonale was present in 64 of the 66 cases (97%), Right Ventricular Hypertrophy (R. V. H) of various grades in 39 cases, and Right Bundle Branch Block (RBBB) in 11. Negative T waves in 2 leads or more were seen in 26 cases, and extraordinarily high, symmetrical, T waves in 5 cases. Generalised poor voltage was seen in 8 cases of whom 2 did not show any evidence of failure. We have one case of Cor Pulmonale in a true dextrocardiac. This patient had a left pleural effusion three years ago, with a small parenchymal focus in the left upper zone. Recently, on one of his routine followup visits, he complained of slight dyspnoea on brisk walking. Examination showed a moderately accentuated P g and the pulmonary artery shadow is somewhat more pronounced than in previous skiagrams. E. C. G. shows a high R wave and a spiky P in V 2 (the equivalent of V 4 in a levocardiac), both evidences of R.V.H. (Fig. 1). TABLE VII Causes of Death Congestive Heart Failure 11 Tuberculosis . . 4 Other causes 3 (Diabetic Coma 1, B. F. fistuala 1, after Monaldi 1) Ind. J. Tub Vol VI, No. 2. 54 COR PULMONALE IN PULMONARY TUBERCULOSIS 55 S. C. KAPOOR 18 of our patients died, 11 in failure, 4 as a result of the primary affection, the cardiac condition not being considered contributory, and three of various other immediate causes. One of these latter died in diabetic acidosis, one as a result of bronchopleural fistula following right pneumonectomy, and the third within a few hours after the institution of a Monaldi drainage for a giant cavity. We had the opportunity of an autopsy in one of our failure cases. This patient had a fairly extensive disease in both upper and mid-zones and Cor Pulmonale had been diagnosed before the onset of failure on the basis of unequivocal signs of R.V.H. i. e. a loud and split P 2 and a parasternal heave. E. C. G. showed very low voltages in all leads, P pulmonale in multiple leads and RBBB with negative T waves in Vj to V 4 . Within a few days he showed a rapidly developing C. H. F., which ended up in full, non pulsatile neck, veins, impalpable cardiac pulsation and poorly heard heart sounds. Two days later he died, total duration of life after failure came on being about 10 days. Mersalyl was exhibited, but to no effect. On autopsy, a large amount of clear, almost colourless, fluid, transudate in nature, was found in the pericardial sac; the heart weighed 365 Cms., pulmonary artery was dilated, being wider that the Aorta, and the right atrium showed moderate hypertrophy. (Fig. 2) Treatment given for failure has been indicated in Table 8. TABLE VIII Therapy in Failure Cases Treatment No. treated Improvement in Mercurials 2 Nil Digoxin 1 Nil Aminophylline with Digoxin 7 Nil Aminophylline and penicillin 1 1 Digoxin with Pen. 1 1 Dig., Aminoph. and Pen. 4 4 Wherever digoxin given, mercurials and/or Diamox also given. As can be seen, Penicillin was the common factor among the cases that showed improvement in failure, although, out of these six cases, two died later, one as a result of a Monaldi drainage and the other in a recurrence of C. H. F. once Penicillin had been stopped. One of our patients came out of failure, and is still alive after ten months, with no recurrence,. after treatment with Penicillin and aminophylline alone. DISCUSSION In the standard text books the aetiological factors in Cor Pulmonale have been listed, in the standard text books, as Chronic Bronchitis with Emphysema, Primary Pulmonary Hypertension, Pneumoconiosis, Bronchial Asthma with Ind. J. Tub., Vol. VI, No. 2. 56 COR PULMONALE IN PULMONARY TUBERCULOSIS S. C. KAPOOR 57 FIG. 3 S. C. KAPOOR 59 [...]... It can be regarded as fairly certain that Cor Pulmonale exists as a complication in tuberculous individuals Diagnosis based on clinical examination and radiology is not always easy, and a large proportion of cases are likely to be missed As mentioned above, accentuation of P2 was our principal clinical finding, and even this was not present in a quarter of the patients Parasternal pulsation, • probably... the average duration of illness in patients admitted to our hospital, which may signify nothing more than coincidence SUMMARY 66 cases of clinically diagnosed Cor Pulmonale in patients of pulmonary tuberculosis have been reviewed The importance of electrocardiographic examination has been stressed The possible reasons for an increase in the incidence of Cor Pulmonale in pulmonary tuberculosis have... According to Richards and Fishman (1956), the important factors in the pathogenesis of Cor Pulmonale are:— (i) decrease in parenchymal elasticity due to chronic inflammatory process, leading to impaired gas exchange, and also, interference with the normal rhythmic changes in pulmonary vascular capacity and pressure secondary to changes hi intrathoracic pressure; (ii) a restriction of the pulmonary vascular... reliable, sign of R.V.H., was seen only in half the patients, i.e., at least half the patients could not have been diagnosed clinically, especially when we remember that accentuated P2 may mean, apart from pulmonary hypertension, just a shift of the heart nearer the anterior chest wall, or an idiopathic dilatation of the pulmonary artery It must be emphasised that early Cor Pulmonale cannot be diagnosed...60 CORE PULMONALE IN PULMONARY TUBERCULOSIS S C KAPOOR 61 62 COR PULMONALE IN PULMONARY TUBERCULOSIS Emphysema, Emphysema due to other causes, conditions like Sarcoidosis diffuse carinomatosis, Hamman—Rich syndrome, Honey-comb lung, and Pulmonary Tuberculosis, after thoracoplasties, etc It is only recently that pulmonary tuberculosis has been mentioned in the literature as an important cause, although... chemotherapy and the consequent prolongation of life in these patients have some influence in this matter How they act, is difficult to say The very fact of longer life may allow the right heart to hypertrophy, against a mild to moderate, long continued, strain of pulmonary hypertension Another explanation, or part of it, may be that our present-day chemotherapy causes fibrosis, hyalinisation and vascular sclerosis... eliminated without having recourse to the E.C.G., and as such, it would probably be wise to subject all cases suspected of Cor Pulmonale on clinical grounds to this investigation Clinical suspicion depends upon a careful examination of the cardiovascular system in all our tubercular cases, repeated every few months, patients with long standing disease being naturally suspect The importance of diagnosing... this complication lies in that it is possible to halt, or at least slow down deterioration in the heart condition As seen among our failure cases, control of secondary lung infection is most important, and this alone may suffice in the management of these patients The literature is unanimous in emphasising the importance of infection in the pathogenesis and development of Cor Pulmonale, as is evident... even in 1946, Spain and Handler had reported a series of 60 cases of Cor Pulmonale in which the majority had tuberculosis as the primary pathology Walzar and Frost (1954), reporting an autopsy series, considered tuberculosis as the most important cause of Cor Pulmonale, having contributed no less than 60% of their cases Their material, of course, was biassed in that tuberculous individuals formed a disproportionately... the alveolar gas exchange by exudates and bronchiolar obstruction, so accentuating this mechanism In our series, diffuse, discrete fibrosis, in otherwise normal looking lungs has been found radiologically in about one-third of all cases, and prolonged expiration over large areas (as an evidence of bronchostenosis) has been seen in just over half Fall in 3 second vital capacity has been seen in a large . enlarged pulmonary artery shadows, in over half of them, this conclusion was arrived at on examination of serial skiagrams after the diagnosis of Cor Pulmonale. comp- lication in tuberculous individuals. Diagnosis based on clinical examination and radiology is not always easy, and a large proportion of cases are likely